本文選題：全胸腔鏡手術 + 胸骨正中切開術�。� 參考：《河北醫(yī)科大學》2017年碩士論文

【摘要】：全胸腔鏡心臟手術是指術野完全依靠胸腔鏡進行顯露,胸腔內手術操作均在胸腔鏡所提供的術野下進行。過去20余年來,隨著體外循環(huán)技術的發(fā)展、手術器械的改進,二尖瓣置換術(mitral valve replacement MVR)已經由原來的胸骨正中切口逐漸向全胸腔鏡化發(fā)展。對于許多病人來說全胸腔鏡體外循環(huán)(cardiopulmonary bypass CPB)下二尖瓣置換術已經成為一個安全、有效的手術方式,同傳統開胸行二尖瓣置換相比,全胸腔鏡體外循環(huán)行二尖瓣置換術在保證手術安全及療效的同時,并沒有增加圍手術期的死亡率,病人則獲得了降低手術創(chuàng)傷,更輕微的疼痛,更少的術后住院天數以及更快的恢復到術前狀態(tài)等諸多好處。如今全胸腔鏡二尖瓣置換術已經是許多心臟中心的常規(guī)手術。我院心臟外科在2012到2106年間成功為20例二尖瓣病變的患者實施了全胸腔鏡體外循環(huán)下二尖瓣置換術,此研究對這些患者的臨床結果進行了分析并總結了全胸腔鏡體外循環(huán)下二尖瓣置換術的經驗。目的:通過比較全胸腔鏡體外循環(huán)下二尖瓣置換術與常規(guī)開胸行二尖瓣置換術的術中及術后指標,探討全胸腔鏡體外循環(huán)下二尖瓣置換術的優(yōu)勢及臨床應用價值。方法:將20例行全胸腔鏡體外循環(huán)下二尖瓣置換術的患者定為全胸腔鏡(totally thoracoscopy TT)組,以年齡、性別、左室射血分數(left ventricular ejection fractions LVEF)、二尖瓣疾病類型及體重指數(body mass index BMI)為匹配因素按成組匹配原則,選取同期行胸骨正中切口、體外循環(huán)下二尖瓣置換術20例作為傳統開胸(conventional sternotomy CS)組,選取總手術時間、體外循環(huán)時間、升主動脈阻斷時間作為術中指標,選取呼吸機輔助呼吸時間、重癥監(jiān)護室(intensive care unit ICU)停留時間、術后應用杜冷丁、嗎啡等阿片類鎮(zhèn)痛藥的病人比例、術后尿管留置時間、術后總引流量、術后住院天數、半年后復查超聲心動圖觀察兩組患者機械瓣功能及心功能情況作為術后指標。對比兩組患者術中及術后指標,以α=0.05為檢驗水準。此研究在取得我院倫理委員會許可且在家屬知情同意情況下進行。結果:TT組與CS組患者相比,平均總手術時間(250.1±7.5min vs.225.4±9.1min;P0.001);平均體外循環(huán)時間(113.1±6.4min vs.84.1±4.6min;P0.001);平均升主動脈阻斷時間(85.2±3.1min vs.59.8±2.2min;P0.001),上述指標TT組均明顯長于CS組且經統計學檢驗有統計學意義。TT組術后呼吸機輔助呼吸時間平均為(12.5±0.8)h,明顯長于CS組(11.0±0.7)h(P0.001),且有統計學意義。TT組與CS組相比平均監(jiān)護室停留時間和平均術后住院天數分別為(38.2±1.5h vs.44.0±1.8h;P0.001)和(8.0±0.8d vs.9.4±0.9d;P0.001),TT組明顯短于CS組,TT組術后總引流量平均為(366.5±29.8ml),明顯少于CS組(499.9±29.5ml P0.001)。TT組術后導尿管留置天數平均為(3.7±0.7d),明顯短于CS組(4.4±0.5d P=0.02)。TT組術后使用杜冷丁、嗎啡等阿片類鎮(zhèn)痛藥的病人比例為20%,亦明顯低于CS組60%(P=0.02)。兩組患者均恢復順利,傷口愈合良好,順利出院,術后6個月復查超聲心動圖,兩組患者機械瓣功能均未見異常,兩組EF值無顯著性差異。結論:同開胸手術相比,全胸腔鏡體外循環(huán)下二尖瓣置換術總手術時間、體外循環(huán)時間、升主動脈阻斷時間和術后輔助呼吸時間較長,但胸腔鏡手術創(chuàng)傷小,ICU停留時間短、住院時間短,恢復時間快,美容效果好。
[Abstract]:Full thoracoscopic surgery means that the operation field is fully exposed by thoracoscopy, and the intrathoracic surgery is performed under the operation field provided by the thoracoscope. Over the past 20 years, with the development of the cardiopulmonary bypass technique, the improvement of the surgical instruments and the mitral valve replacement (mitral valve replacement MVR) have evolved from the original median sternum incision. For many patients, full thoracoscopic cardiopulmonary bypass CPB mitral valve replacement has become a safe and effective surgical procedure. Compared with the traditional thoracotomy for mitral valve replacement, full thoracoscopic cardiopulmonary bypass for mitral valve replacement can ensure the safety and efficacy of the operation. There was no increase in the peri operative mortality rate, and the patient received many advantages, such as lower surgical trauma, less pain, less postoperative hospitalization, and faster recovery to the pre operation state. Now full thoracoscopic mitral valve replacement has been a routine hand in many heart centers. Our hospital has a success of 2 between 2012 and 2106. 0 patients with mitral valve disease performed mitral valve replacement under full thoracoscopic cardiopulmonary bypass. This study analyzed the clinical results of these patients and summarized the experience of mitral valve replacement under full thoracoscopic cardiopulmonary bypass. Objective: To compare mitral valve replacement and conventional thoracotomy for mitral valve replacement under full thoracoscopic extracorporeal circulation. The advantage and clinical value of intraoperative and postoperative mitral valve replacement under full thoracoscopic cardiopulmonary bypass were discussed. Methods: 20 patients were treated with total thoracoscopic mitral valve replacement (totally thoracoscopy TT), with age, sex, and left ventricular ejection fraction (left ventricular ejection fract). Ions LVEF), the type of mitral valve disease and the body mass index (body mass index BMI) as matching factors according to the group matching principle, select the median sternum incision in the same period, and 20 cases of mitral valve replacement under extracorporeal circulation as the traditional open chest (conventional sternotomy CS) group, select the total operation time, the extracorporeal circulation time, the ascending aorta blocking time. Intraoperative indexes, ventilator assisted respiration time, intensive care unit ICU stay time, the proportion of opioid analgesics such as dopenin and morphine, postoperative indwelling time of urethral catheterization, postoperative total flow rate, postoperative hospitalization days, and two groups of patients with mechanical valve function and heart after half a year were examined by echocardiography. Function as a postoperatively. Compared to the two groups of patients during and after the operation and postoperative indicators, the level of alpha =0.05 was tested. This study was carried out under the permission of the ethics committee of our hospital and under the informed consent of the family members. Results: the average total operation time (250.1 + 7.5min vs.225.4 + 9.1min; P0.001) was compared with the CS group, and the average extracorporeal circulation was compared. Between (113.1 + 6.4min vs.84.1 + 4.6min, P0.001), the mean ascending aorta blocking time (85.2 + 3.1min vs.59.8 + 2.2min; P0.001), the above indexes were significantly longer in the CS group than in the CS group and statistically significant in the.TT group (12.5 + 0.8) h, which was significantly longer than that of the group (11 + 0.7). The average length of stay of the.TT group and the average postoperative hospital stay were (38.2 + 1.5h vs.44.0 + 1.8h, P0.001) and (8 + 0.8d vs.9.4 + 0.9d, P0.001), and the TT group was significantly shorter than that of the CS group. The average flow rate after operation was (366.5 +), which was significantly less than that of the group (499.9 +). The average number of days was (3.7 + 0.7d), obviously shorter than group CS (4.4 + 0.5d P=0.02).TT, the proportion of opioid analgesics, such as morphine, was 20%, and 60% (P=0.02) in the group CS. The two groups recovered smoothly, the wound healed well, was discharged from the hospital smoothly, the ultrasonic cardiogram was rechecked 6 months after the operation, and the function of the two group of the mechanical valves was not. There was no significant difference in the EF value of the two groups. Conclusion: compared with the open thoracotomy, the total operation time, the time of extracorporeal circulation, the time of extracorporeal circulation, the interruption time of the ascending aorta and the time of assisted respiration were longer, but the thoracoscopic surgery was small, the time of ICU was short, the time of hospitalization was short, the time of recovery was fast, and the beauty effect was improved. OK.
【學位授予單位】：河北醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R654.2

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